Laparoscopic Inguinal Hernia Repair—TEP Technique
Pradeep K. Chowbey
The inguinal hernia repair has been a controversial area in the surgical practice from time it has
been conceived. The history of inguinal hernia repair over several decades implies how
innovations are adopted into surgical practice through combination of scientific and subjective
processes. The techniques of laparoscopic hernia repair have evolved in parallel with experience
and technology. In the laparoscopic procedure, tension free repair is achieved by placement of a
prosthetic mesh to cover the entire groin area including the sites of direct, indirect and femoral
hernia. The laparoscopic approach is based on the principle of tension free repair, which has
been well established by open operation by Nyhus and Stoppa. The greater availability of space
in the extraperitoneal approach facilitates the insertion of a much bigger mesh.
Patient selection
TEP groin hernia repair is an advanced laparoscopic procedure. It requires greater skills of
laparoscopic dissection and manipulation as the working space available is limited. It has a long
learning curve and must be done only after acquiring experience in basic laparoscopic
procedures and when the learning curve is over. Today, we are well past the learning curve and
have performed well over thousand laparoscopic groin hernia repairs. Except for strangulated
hernia, at present there are no absolute contraindications for this procedure. Relative
contraindications include patients unfit for anesthesia, obese and pregnant patients and patients
with a history of lower abdominal surgery.
Preoperative preparation
A thorough history of the presenting complaints and other comorbid conditions should be taken.
Specific measures should be taken if the patient is on drugs like Aspirin and warfarin, oral
hypoglycemic agents etc. Besides routine hematological investigations, other specific
investigations like X-Ray chest, ECG, coagulation profile, pulmonary function test etc should be
done for patients with history of cardiac / pulmonary pathology. A written consent should be
taken explaining the probable complications and possibility of conversion to open surgery.
Following preanesthetic check up and clearance for surgery, the patient is kept fasting overnight.
The patient is prepared adequately.
Surgical Technique
The procedure is done under general anesthesia (regional anesthesia if the patient is unfit for
general anesthesia). The patient is catheterized or asked to empty the bladders before surgery and
prophylactic antibiotic is given at the time of induction of anesthesia. After induction, complete
reduction of the contents of the hernial sac is ensured.
Extraperitoneal access
A 10mm infraumbilical transverse incision is made. The anterior rectus sheath is exposed and
transverse incision is then made on the anterior rectus sheath to one side of the midline to avoid
inadvertent opening of the peritoneum [Fig.1]. The margins of incised sheath are held in stay
sutures using vicryl 1-0 [Fig.2]. The rectus muscle is retracted laterally from the midline and by finger
dissection a space is created between the rectus muscle and the posterior rectus sheath.
Fig. 1: Transverse infraumbilical incision with incision in anterior rectus sheath
Fig. 2: Stay sutures over incised anterior rectus sheath
Balloon dissection of the extraperitoneal space
A self made balloon is then inserted in this preperitoneal space. The balloon trocar used by us is
an indigenously made trocar where we tie two finger stalls of a size 8 latex surgical glove on the
tip of the 5 mm laparoscopic suction cannula [Fig. 3]. The balloon trocar is the inflated with 100150ml of saline. It not only creates an initial working space but also brings about hemostasis
by balloon tamponade. The balloon is then deflated and the cannula is removed.
A 10 mm Hassan’s cannula (blunt tip cannula) mounted with a conical sleeve is then introduced
into the preperitoneal space through the infraumbilical incision [Fig. 4]. The conical sleeve
snuggly fits into the incision and is secured with stay sutures. The insufflation tubing is attached
to the Hasson’s Cannula and insufflation is begun with pressure setting at 12 mm Hg. A 10 mm
30° telescope is used. The camera is introduced through the sub umbilical port and preperitoneal
space is visualized. The other two working ports are placed in the preperitoneal space. First, a 5
mm port is placed about 2-3 cm above the pubic symphysis in the midline and second, a 5/10
mm port is placed in the midline midway between the two placed ports (subumbilical and
suprapubic) [Fig. 5 & 6].
Fig. 3: Indigenous balloon trocar
Fig. 4: Hassan’s cannula introduced in sub umbilical port
Dissection of the extraperitoneal space
The surgeon stands on the side opposite to the operating side / or side where hernia is present.
Dissection in extra peritoneal space begins by dividing the loose areolar tissue in the midline
using sharp and blunt dissection. The first landmark / reference point i.e. the pubic bone is
identified which appears as white glistening structure in the midline. The pubic bone is
visualized and bared of all connective tissue creating a shelf extending about 2-3 cm in the
retropubic space, which acts as a shelf to place the mesh [Fig.7].
The dissection is then traced laterally towards the side of the hernia. In case of direct hernia, the
hernial sac is visualized as a weakness in the Hasselbach’s triangle medial to the inferior
epigastric vessels. On the other hand, in the indirect hernia, the inferior epigastric vessels are
seen before the hernial sac, which is encountered laterally. Once the adhesions are lysed or
hernial sac is reduced as in direct hernia, the anatomical landmarks which now become visible
are Cooper’s ligament, iliopubic tract, femoral canal and the inferior epigastric vessels [Fig. 8,
9].
Fig. 5: Port placement for TEP
Fig. 6: Preperitoneal space
Fig. 7: Preperitoneal space
Fig. 8: Left direct hernial defect seen after dissection
Fig. 9: Right direct hernial defect
The spermatic cord lies immediately inferior and lateral to the inferior epigastric vessels. The
adhesions all around the cord are lysed with caution as the external iliac vessels lie just below the
cord structures. The peritoneal extension (sac) is seen as a white glistening structure lying
anterolateral to the cord [Fig.10]. The sac is completely dissected off the cord structures and
reduced. In cases of complete hernia, attempt should not be made to completely reduce the sac as
excessive traction and dissection causes severe postoperative pain and edema. The sac should be
transected and ligated using a catgut endoloop or by intracorporeal sutures, leaving the distal sac
open in situ [Fig.11].
Fig. 10: Right indirect hernial sac with cord structures
Fig. 11: Dissected and ligated right indirect hernial sac
The peritoneal sac with reflection is completely reduced. The vas deferens is seen lying
separately on the medial side and gonadal vessels are seen on the lateral side forming a triangle.
This triangle, known a “triangle of doom”, is bounded medially by the vas deferens laterally by
gonadal vessels with its apex at the internal inguinal ring and the base is formed by the
peritoneum. No dissection should be carried within this triangle as it contains the external iliac
vessels.
Dissection is continued lateral to the cord structures to create adequate space for the placement
of mesh. The lateral space contains loose aerolar tissue, which is completely divided using sharp
and blunt dissection. The psoas muscle is seen lying on the floor on which lateral cutaneous
nerve of thigh and genito femoral nerve can be seen transversing. The anterior superior iliac
spine marks the lateral boundary of the dissection.
After creating the lateral space adequately the mesh is introduced through the 10mm
subumbilical port [Fig.12]. The mesh is placed over the space created so that it covers the sites of
direct, indirect, femoral and obturator hernias [Fig.13]. The mesh is the secured in place with the
help of fixation devices like helical fasteners, staples anchors etc. depending upon the preference
of the surgeon. After adequately spreading the mesh, which extends from the midline medially,
to lying over the psoas muscle on the lateral side, preperitoneal space is deflated. In cases of
bilateral hernias the similar procedure can be done on both the sides through the same three ports
made for unilateral repair.
Fig. 12: Rolled prolene mesh
Fig. 13: Prolene mesh being placed for repair